Schizophrenia

What is schizophrenia?
A thought process disorder. It is characterised by disruption to a person's perceptions, emotions and beliefs.
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What is type 1 schizophrenia?
More acute, has more of the positive symptoms, but responds better to treatment.
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What is type 2 schizophrenia?
Chronic, has more of the negative symptoms and is less responsive to treament. It affects mood, though processes and the ability to determine what is reality.
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What is a psychosis?
A severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality.
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What is a neurosis?
Excessive and irrational anxiety or obsession.
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Statistics - will sufferers recover?
25% will get better after one episode of the illness, 50-65% will improve, but continue to have bouts of the illness, the remainder will have persistent difficulties (Stirling & Hellewell, 1999).
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How do we classify schizophrenia?
Manuals. ICD (International Classification of Diseases) recognises a range of subtypes. DSM (The Diagnostic and Statistical Manual of Psychiatric Disorder) recognises subtypes.
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Disorganised schizophrenia
Disorganised speech, behaviour and flattened effect. Inappropriate/unexpected behaviour. Strange mannerisms & gestures. Causes significant dysfunction in aily life, self-care, and interaction with others.
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Catatonic schizophrenia
Assume peculiar postures and are usually speechless. Rigidness and motionless or agitated and moving constantly. Strange facial expressions and mimic the behaviour of others.
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Paranoid schizophrenia
Delusions that have a theme. Auditory hallucinations may accompany them. Anger, irratible, anxiety are prominent symptoms. Violent. Able to live, work and care for themselves. The onset is often later in life.
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Undifferentiated schizophrenia
Given to a lack of catatonic, paranoia or disorganisd speech. May resemble other illnesses. Tend to have an insight.
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Residual schizophrenia
Positive symptoms have disappeared. Negatve sysmtpoms remain and may be interrupted only briefly by mildly disorganised speech or strange behaviour.Symptoms can last indefinitely, or they can lead to complete recovery, thoug this is rare.
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What are positive symptoms?
Behaviours that are additional to normal life experiences and concern osing touch with reality.
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Examples of positive symptoms
Hallucinations, delusions, delusions of grandeur, paranoia, disorganisd speech, delusions of control, catatonic behaviour.
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What are negative symptom
Behaviours that detract from normal life experiences; a lack of something.
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Examples of negative symptoms
Withdrawal, language impairments, avolition, lack of emotion, stereotyped behaviours, psychomotor disturbance, affectivflattening, anhedonia.
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ICD
Diagnostic book.
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What are the criteria A symptoms for the DSM?
Criteria A: delusions, hallucinations, disorganised speech, catatonic behaviour, negative symptoms.
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What are the criteria B symptoms for the DSM?
Social/occupational dysfunction: significant portion of time since onset, one or more major areas of functioning are below expected.
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What are the critera C symptoms for the DSM?
Duration: continuous sign of disturbance for at least 6 months.
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Co-morbidity
The co-existence of two separate conditons/illnesses at the same time. Cmplicates the diagnosis and may mean that different treatment programmes are needed side by side.
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Symptom overlap
When the symptoms of two mental illnesses are very similar. It's problematic betwen schizophrenia and bipolar disorder. Also with depressi, intoxication through drugs & autism.
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What is deviation from social norms?
Social norms are implicit rules about how we ought to behave in society. Anything that violates these are abnormal.
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What is statistical deviation?
If behaviour is statistically unusual, it is classed as abnormal.
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What is deviation from ideal mental health?
A list of criteria that we would consider normal, and therefore an abce of any of these would help us define abnormality.
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What is failure to function adequately?
Inability to carry out everyday tasks and lead what would be considered a 'normal' life.
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What are the emotional symptoms of phobias?
Marked & persistent fear, excessive & unreasonable, anxiety & panic, triggered by the thought of it.
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What are the behavioural symptoms of phobias?
Avoidance, freeze, faint, fight-or-flight response.
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What are the cognitive symptoms of phobias?
Irrational thoughts and an insight.
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What are the emotional symptoms of depression?
Empty, sadness, worthless, low self-esteem, loss of interest, anger, hopeless.
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What are the behavioural symptoms of depression?
Reduced/increased level of activity, reduced energy, tiredness, insomnia, agitated & restless, loss of appetite/too much.
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What are the cognitive symptoms of depression?
Irrational thoughts, guilt, worthlessness, suicidal thoughts, an insight.
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What are the emotional symptoms of OCD?
Anxiety, distressed, aware they're excessive, embarrassment, shame.
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What are the behavioural symptoms of OCD?
Compulsive behaviours, repetitive & unconcealed, they have to do it, not in a realistic way, avoidance.
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What are the cognitive symptoms of OCD?
Recurrent & intrusive thoughts, uncontrollable ideas, doubts, impulses r images; an insight.
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What impact does this have for getting diagnosed and receiving treatment?
Schizophrenia patients don't have an insight; they believe it's the same for everyone.
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If diagnosis is reliable...
We should be able to get the same diagnosis from different professionals.
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If diagnosis is valid...
There should be a genuine measurement of schizophrenic symptoms.
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What are the main assumptions of the biological approach?
The role of genetics and neurochemicals; gather scientific evidence.
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Chance of developing it
Less than 1% for an individual, but if you have a close relative with schizophrenia, the risk increases to between 6 and 17%.
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Gottesman's family study found that...
Children with 2 schizophrenic parents had a concordance rate of 46%, children with 1 schizophrenic parent a rate of 13%, and siblings a concordance rate of 9%.
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Gottesman's research shows that...
Schizophrenia is more common among biological relatives of a person with schizophrenia and that the clsoer the degree of genetic relatedness, the greater the risk.
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Joseph's twin study found that...
The pooled data for all schizophrenic twin studies carried out prior to 2001 showed a concordance rate for MZ twins of 40.4% and 7.4% for DZ twins.
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Joseph's research shows that...
A concordance rate for MZ twins that is many times higher than that for DZ twins.
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Tienari's adoption study found that...
Of the 164 adoptees whose biological mothers had been diagnosed with schizophrenia 6.7% also received a diagnosis of schizophrenia, compared to just 2% of the 197 control adoptees.
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Tienari's research shows that...
The genetic liability to schizophrenia had been 'decisively confirmed'.
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Evaluation of genetic explanations: concordance rates
Do show a genetic link, however, they clearly show genetics is not the only explanation. Adoption studies (1% chance to 6%).
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Evaluation of genetic explanations: variables
Can't establish cause & effect; not all are controlled (environment?); age adopted at; can't account for all factors; type?
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The dopamine hypothesis states that...
An excess of dopamine in the brain is associated with the positive symptoms. If you have too much dopamine, it leads to the positive symptoms of schizophrenia
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Drugs that increase dopaminergic activity...
Amphetamine. 'Normal' people that are exposed develop the positive symptoms.
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What about Parkinson's disease?
Some people with Parkinson's disease, charaterised by low dopamine levels, who take the drug L-dopa to raise their levels, have been found to develop positive schizophrenic symptoms.
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Drugs that decrease dopaminergic activity...
If reduced too much, can develop Parkinson's disease. However, antipsychotic drugs can take away the positive symptoms.
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The revised dopamine hypothesis (Davis & Kahn, 1991)...
Positive symptoms are caused by an excess of dopamine. The negative symptoms are thought to arise from a deficit of dopamine in areas of the prefrontal cortex.
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Supporting evidence comes from neural imaging (Patel, 2010)...
PET scans to assess dopamine levels in schizophrenic and 'normal' individuals found lower levels of dopamine in the dorsolateral prefrontal cortex of schizophrenic patients compare to their normal controls.
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Evaluation of the dopamine hypothesis: scientific evidence
Brain scans to show increased levels of dopamine. Genetic explanation doesn't have scientific evidence to suppport. Led to treatment - druguce levels of dopamine; has been successful.
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Evaluation of the dopamine hypothesis: no account for negative symptoms
Which came first? Did schizophrenia cause high dopamine levels or were some people born before noticing high levels of dopamine. Can't establish cause & effect.
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What are the main assumptions of the cognitve approach?
Behaviour comes from our mental processes; which causes schizophrenia. Input - Processing - Output.
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How could our family be a possible cause for schizophrenia?
Stress can trigger a schizophrenic episode.
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Cognitive explanatons of schizophrenia 1...
Propose that abnormalities in cognitive function are a key component of schizophrenia. Not enough information received = faulty processing. Delusions - interpretations of their experiences are controlled by inadequate informaion processing.
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Cognitive explanatons of schizophrenia 2...
Hallucinations - excessive attention on auditory stimuli and so have a higher expectancy for the occurrence of a voice. Assume that every sound they hear is real.
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Evaluation of cognitive explanations: supportive evidence for the cognitive model of schizophrenia
Sarin & Walin: review of research; positive symptoms - origins in faulty cognition. E.g. schizophrenics with hallucinations had impaired self-monitoring. Negative symptoms also displayed dysfunctional thought processes.
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Evaluation of cognitive explanations: an integrated model of schizophrenia
Model deals with one aspect, but ignores other aspects (Haves & Murray). Early vulnerability factors and exposure to social stressors, sensitises the dopamine system, causing it to release dopamine. Results: paranoia & hallucinations.
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Family dysfunction
The presence of problems within a family that contribute to relapse rates in recovering schizophrenics, including lack of warmth between parents & children, dysfunctional communication patterns and parental over protection.
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Family dysfunction: double bind theory
Contradictory messages from parents & children (Bateson, 1956). Prevent the development of an internally coherent construction of reality, and in the l run,this manifests itself as schizophrenic symptoms (negative).
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Family dysfunction: expressed emotion 1
Family of a psychiatric patient talk about them in a critical or hostile manner or in a way that indicates emotional over-involvement.
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Family dysfunction: expressed emotion 2
Kuipers (1983): EE relatives talk more and listen less. High levels are most likely to influenceelapse rates. A patient returning to a family with high EE is above 4x more likely to relapse than a patient whose family is in EE.
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Family dysfunction: expressed emotion 3
Patients have a lower tolerance for intense environmental stimuli, particularly intense emotional comments and interactions with family members. Negative emotional climate in thse families arouses the patient and leads to stress.
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Evaluation of the family dysfunction: family relationships
Tiernari: adopted children with schizophrenic biological parents are more likely to lop it. However, only emerged in situations where the adopted family was rated as disturbed. Appropriate environmental conditions.Genetics aren't the only cause.
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Evaluation of the family dysfunction: double bind theory
Berger: schizophrenics reported a higher recall of double bind statements by their mothers than non-schizophrenics. May be affected by their schizophrenia.
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What is the basic principle of drug therapy?
Drug to reduce levels of dopamine in the brain.
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When was drug therapy for schizophrenia introduced?
In the 1950s. Before this, patients would be imprisoned.
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When/why is drug therapy recommended?
Medical condition - medication so it legitimises it. Patients feel better as it takes the blame away. Good as it is a short-term solution to calm the symptoms down in order to start talking.
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Typical antipsychotics
1950S; reduce effects of dopamine; reduce symptoms; dopamine antagonists; block action; 60-75% of dopamine receptors must be blocked for effectiveness.
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Side effects of typical antipsychotics
Cause movement problems; Parkinson's disease symptoms; Tardive dyskinesia (involuntary facial movements); urinary problems.
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Examples of typical antipsychotics
Chlorpromazine, fluphenazine, haloperidol.
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Atypical antipsychotics
Newer drugs; carry a lower risk of side effects; beneficial effect on negative symptoms and cognitive impairment; suitable for treatment-resistant patients; block action; reduce levels of dopamine temporarily.
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Side effects of atypical antipsychotics
Weight gain; diabetes; cardiovascular conditions; reduced white blood cell count (using clozapine).
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Examples of atypical antipsychotics
Clozapine, quetiapine, olanzapine.
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Evaluation of drug therapy: can't treat all cases
Typical antipsychotics reduce dopamine levels by 75% so syoms of schizophrenia are reduced, but they develop Parkinson's disease symptoms as a side effect.
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Evaluation of drug therapy: effective
Drugs work quickly. A review of 6,000 cases. Swapped medication placebo. 64% relapsed within a few months. Unethical study. Effective - has to keep taking drugs.
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Evaluation of drug therapy: side effects
Vary with typical & atypical drugs. Typical drugs reduce dopamine levels, but are reduced by 75% which leads to Parkinson's disease; lose emotion; don't feel 'normal'. Increases dropout rates = less successful.
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What is cognitive behavioural therapy?
A combination of cognitive therapy and behavioural therapy.
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What are the basic principles of CBT?
Depression is caused by irrational/faulty thinking. Aims: correct irrational thoughts. Ellis' ABC model.
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What is CBT for psychosis (CBTp)?
The basic assumption is that people have distorted beliefs, which influence their feelings and behaviours in maladaptive ways.
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The nature of CBTp
Therapist lets the patient develop their own alternatives to the previous maladaptive beliefs. Alternative explanations & coping strategies. Pants trace back the origins of their symptoms to see how they might have developed.
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CBTp: step 1 -assessment
Patient expresses their own thoughts about their experiences.
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CBTp: step 2 - engagement
The use of Socratic questioning and empathy creates a therapeutic relationship. Good relationship needed; unconditional positive regard.
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CBTp: step 3 - the ABC model
Patient can organise their thoughts and feelings. (A) activating event - identify stressors; (B) belief - irrational thoughts; (C) consequence - behaviour.
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CBTp: step 4 - normalisation
De-catastrophising psychotic experiences which are placed on a continuum with normal experiences, making the possibility of recovery seem less distant. Make them aware of other sufferers.
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CBTp: step 5 - critical collaborative analysis
Once trust is formed, gentle questioning is used to help the patient appreciate maladaptive beliefs. Challeneg irrational thoughts. Unconditional positive regard.
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CBTp: step 6 - developing alternative explanations
The patient should develop their own alternatives to previous maladaptive assumptions. Look at coping strategies. Unconditional positive regard; work together.
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Evalution of CBTp: drugs vs CBTp
(D): calms symptoms; anyone with a doctor can get access to antipsychotics. (CBTp): cost per session; wait to be referred; have to build rapport or patient won't talk; not easily accessible.
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Evalution of CBTp: advantages
Unconditional positive regard - rapport built between therapist & patient; trust = communicate more; someone to talk to; self-awareness; long-term.
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Evalution of CBTp: preference for drug therapy
Calms symptoms down before talking; takes blame away; suggests there is a cause.
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What are the main aims of family therapy for schizophrenia?
Long-term strategy. Helps every member of the family to have a greater understanding of schizophrenia, supports them and the patient is left feeling not as isolated.
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What have NICE said?
All individuals diagnosed with schizophrenia who are in contact with or live with family members.
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What is the nature of family therapy?
3-12 months. 10+ sessions. Reduce the level of expressed emotion (relapse); provides families with information, supports them, resolves practical problems; involves the patient; benefits everyone; not just the patient.
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Strategy of family therapy: psychoeducation.
Greater understanding of schizophrenia. Dealing with it in a better way.
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Strategy of family therapy: alliances
With those who care for the patient.
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Strategy of family therapy: emotional climate
Reduce the burden of care for the family members.
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Strategy of family therapy: solving problems
Anticipate ways to solve problems.
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Strategy of family therapy: anger/guilt
Reduce the feelings of anger and guilt.
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Supporting evidence for FT: Pharoah (2010) - procedure
53 studies to investigate the effectiveness of family intervention. In Europe, Asia & North America. Compared to 'standard care'.
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Supporting evidence for FT: Pharoah (2010) - findings 1
Compliance with medication - more likely to continue their drug therapy when receiving family therapy.
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Supporting evidence for FT: Pharoah (2010) - findings 2
Reduction in relapse & readmission - during treatment and in the 24 months after.
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Family therapy vs drug therapy 1
FT is an extra therapy; drugs first to get the patient thinking more rationally.
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Family therapy vs drug therapy 2
DT is just for the patient, whereas FT supports everyone as it changes the environment.
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Family therapy vs CBTp 1
Both cost a lot of money and take a lot of time.
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Family therapy vs CBTp 2
For FT, it may be difficult to get all the family together (e.g. jobs), whereas CBTp is just for the patient.
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Family therapy vs CBTp 3
FT gives the patient a voice; it's directed by them, not the therapist. They talk about what is beneficial to them; how they want their family to help them.
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Evaluation of family therapy: economic benefits
Less chance of relapse - no hospitalisation; save money. Go back to work. Therapy is expensive, but savings outweigh it for not being hospitalised. Patient & family save a lot of money.
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Evaluation of family therapy: positive impact on family members
Provides support and removes the burden of care. Educate family members; develop coping strategies. Improves family situation. Less reductionist as everyone is involved. Beneficial as stress is removed, which can prevent a schizophrenic episode.
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What are token economies?
A form of therapy where desirable behaviours are encouraged by the use of selective reinforcements. Rewards are given as secondary reinforcers when individuals engage in socially desirable behaviours; can be exchanged for primary reinforcers.
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Where are token economies used?
In hospitals to help institutionalised people with schizophrenia to gain more control over their daily lives and increase positive behaviours.
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What are token economies based on?
The operant conditioning theory.
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What are primary reinforcers?
Anything that give pleasure (e.g. food) or remove unpleasant states. Do not depend on learning in order to acquire their value.
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What are secondary reinforcers?
Initially have no value to the individual., but acquire their reinforcing properties as a result of being paired with primary reinforcers.
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Token economy cycle: stage 1
Tokens are paired with rewarding stimuli and so become secondary reinforcers.
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Token economy cycle: stage 2
Patient engages in 'target' behaviours or reduces inappropriate ones.
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Token economy cycle: stage 3
Patient is given tokens for engaging in these target behaviours.
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Token economy cycle: stage 4
Patients trades these tokens for access to desirable items or other privileges.
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Supporting evidence for TE: Ayllon & Azrin (1968) - procedure
Ward of female schizophrenics; hospitalised for years. Given plastic tokens with 'one gift' on, which could be exchanged for privileges.
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Supporting evidence for TE: Ayllon & Azrin (1968) - findings
The use of token economies with these patients increased dramatically the number of desirable behaviours that the patients performed each day.
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Assigning value to the token
To give the neutral token some 'value', it needs to be first be repeatedly presented alongside or immediately before the reinforcing stimulus.
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Result of assigning value to the token
The neutral tokens become secondary reinforcers, and so can be used to modify behaviour.
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Reinforcing target behaviours
When patients perform the desirable target behaviours, the clinician awards them tokens. When a token can be exchanged for a vairety of different privileges and rewards, it is referred to as a generalised reinforcer.
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Supporting evidence for reinforcing target behaviours: Sran and Borrero (2010) found that...
All participants had higher rates of responding in the sessions where tokens could be exchanged for a variety of items.
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The 'trade' of token economies
The rewards include food, sweets or privileges, such as watching a movie. During the early stages, frequent exchange periods meant that patients can be quickly reinforced and target behaviours can then increase in frequency.
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Supporting evidence for trading TE: Kazdin (1977)
The effectiveness of the token economy may decrease if more time passes between presentation of the token and exchange for the backup reinforcers.
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Evaluation of TE: ethics
Do patients have the same list of 'target' behaviours? Some patients may already wash themselves, for example, and some may not and if they get rewarded then they will too. If they already did that; won't learn it's a desirable behaviour. Unfair.
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Evaluation of TE: less useful for patients living in the community
It has only been shown to work in a hospital setting. Difficult to administer care and support to outpatients compared to hospitalised patients who receive 24 hour care.
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Evaluation of TE: ethical concerns
Clinicians may exercise control over important primary reinforcers such as food, privacy or access to activities that alleviate boredom. It is generally accepted that all human beings have certain basic rights to food and privacy.
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What is meant by the diathesis-stress model?
Explains mental disorders as the result of an interaction between biological (diathesis) and environmental (stress) influences.
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Diathesis
Genetic component for vulnerability. Identical twins: 50% chance; environment plays a role too in whether the twin develops schizophrenia.
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Stress
Stressful life events can trigger schizophrenia. Can be childhood trauma or living in a highly urbanised environment.
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Diathesis + stress
Genetic blueprint + live in an overcrowded environment = stress = schizophrenia.
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The additive nature of DSM: vulnerable person
Lots of minor stressful events + highly vulnerable individual = schizophrenia.
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The additive nature of DSM: not so vulnerable
One major stressful event + individual who has a low vulnerability = schizophrenia.
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Evaluation of DSM: diatheses may not be exclusively genetic
Emphasise vulnerability in genetic influence. Cause neurochemical abnormalities that result in an increased risk. It can also be a result from brain damage from environmental factors.
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Evaluation of DSM: urban environments are not necessarily more stressful
Living in densely populated urban areas is a stress factor. Study found that there weren't differences in rural-urban areas in mental health among women in New Zealand.
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Evaluation of DSM: limitations of Tiernari
Assessing family functioning at one given time only. Doesn't reflect developmental changes. Impossible to determine how much stress observed is assigned to the family.
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Other cards in this set

Card 2

Front

More acute, has more of the positive symptoms, but responds better to treatment.

Back

What is type 1 schizophrenia?

Card 3

Front

Chronic, has more of the negative symptoms and is less responsive to treament. It affects mood, though processes and the ability to determine what is reality.

Back

Preview of the back of card 3

Card 4

Front

A severe mental disorder in which thoughts and emotions are so impaired that contact is lost with external reality.

Back

Preview of the back of card 4

Card 5

Front

Excessive and irrational anxiety or obsession.

Back

Preview of the back of card 5
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